Venoarterial extracorporeal membrane oxygenation or standard care in patients with cardiogenic shock complicating acute myocardial infarction: the multicentre, randomised EURO SHOCK trial

DOI: 10.4244/EIJ-D-23-00204

Amerjeet  Singh Banning
Amerjeet Singh Banning1,2, MBBS, BSc (Hons), PhD, MRCP; Manel Sabate3, MD, PhD, FESC; Martin Orban4, MD; Jay Gracey2, BA, RN; Teresa López-Sobrino3, MD; Steffen Massberg5, MD, PhD; Adnan Kastrati5, MD, FESC; Kris Bogaerts6, PhD; Tom Adriaenssens7, MD; Colin Berry8, ChB, PhD, MB, FACC, FRCP (Glasg); Andrejs Erglis9, MD, PhD, FESC, FACC; Steven Haine10, MD, PhD; Truls Myrmel11, MD, PhD; Sameer Patel12, MBBS, FRCA, MRCP, FFICM; Irene Buera13, MD; Alessandro Sionis14, MD, PhD; Victoria Vilalta15, MD, PhD; Hakeem Yusuff1, FRCA, MRCP, FFICM; Christiaan Vrints10, MD, PhD, FESC, FACC; David Adlam2, DPhil, BCh, BM; Marcus Flather16, MBBS, BSc, FRCP, MBA; Anthony H Gershlick1,2, MBBS, BSc, FRCP
1. Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK; 2. Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; 3. Consorci Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Cardiovascular Institute, Hospital Clinic, Barcelona, Spain; 4. Medizinische Klinik und Poliklinik I, LMU University Hospital Munich, Munich, Germany; 5. Department of Cardiology, Deutsches Herzzentrum Muenchen, German Center for Cardiovascular Research (DZHK), Munich, Germany and Partner Site Munich Heart Alliance, Munich, Germany; 6. Department of Public Health and Primary Care, KU Leuven, I-Bio Stat, Leuven, Belgium and UHasselt, I-Bio Stat, Diepenbeek, Belgium; 7. University Hospitals Leuven, Leuven, Belgium and Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; 8. University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK and Robertson Centre for Biostatistics, Glasgow, UK; 9. Pauls Stradins Clinical University Hospital, Riga, Latvia and the University of Latvia, Riga, Latvia; 10. Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium and Department of Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium; 11. Universitetssykehuset Nord-Norge, Tromsø, Norway; 12. King’s College Hospital and Faculty of Life Sciences & Medicine, King’s College London, London, UK; 13. Hospital Universitario Vall d’Hebron, VHIR, Universidad Autonoma de Barcelona, Barcelona, Spain; 14. Cardiology Department, Intensive Cardiac Care Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain and Universitat Autònoma de Barcelona, Barcelona, Spain and Centro de Investigación Biomèdica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; 15. Interventional Cardiology Unit, Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; 16. University of East Anglia, Norwich, UK and Norfolk and Norwich University Hospitals, Norwich, UK

Background: Cardiogenic shock (CGS) occurs in 10% of patients presenting with acute myocardial infarction (MI), with in-hospital mortality rates of 40-50% despite revascularisation.

Aims: The EUROSHOCK trial aimed to determine if early use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) could improve outcomes in patients with persistent CGS following primary percutaneous coronary intervention (PPCI).

Methods: This multicentre, pan-European trial randomised patients with persistent CGS 30 minutes after PPCI of the culprit lesion to receive either VA-ECMO or continue with standard therapy. The primary outcome measure was 30-day all-cause mortality in an intention-to-treat analysis. Secondary endpoints included 12-month all-cause mortality and 12-month composite of all-cause mortality or rehospitalisation due to heart failure.

Results: Due to the impact of the COVID-19 pandemic, the trial was stopped before completion of recruitment, after randomisation of 35 patients (standard therapy n=18, VA-ECMO n=17). Thirty-day all-cause mortality occurred in 43.8% of patients randomised to VA-ECMO and in 61.1% of patients randomised to standard therapy (hazard ratio [HR] 0.56, 95% confidence interval [CI]: 0.21-1.45; p=0.22). One-year all-cause mortality was 51.8% in the VA-ECMO group and 81.5% in the standard therapy arm (HR 0.52, 95% CI: 0.21-1.26; p=0.14). Vascular and bleeding complications occurred more often in the VA-ECMO arm (21.4% vs 0% and 35.7% vs 5.6%, respectively).

Conclusions: Due to the limited number of patients recruited to the trial, no definite conclusions could be drawn from the available data. Our study demonstrates the feasibility of randomising patients with CGS complicating acute MI but also illustrates the challenges. We hope these data will inspire and inform the design of future large-scale trials.

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